6. Project Summary/Abstract Objectives/Hypothesis: This study will improve care for veterans and provide a benchmark for educational programs to link educational activities and patient outcomes. This proposal will unleash the improvement capabilities of those who are at the front lines of care - the resident physicians. Understanding how learners can improve systems and patient outcomes at the point of care is a vital next step in the evolution of clinical teaching. This project will identify what works for resident-led improvement and under what circumstances. This work will inform all residency training programs - both VHA and non-VHA - and help them improve the care that is delivered in their own programs. It will strengthen VHA's leadership in developing novel educational programs. The immediate objective is to determine the impact of an educational design for internal medicine residents that is focused on systems knowledge, quality improvement, and interprofessional care. The long term objective is to create a system of education within VHA that integrates excellent patient care with system knowledge and exceptional professional development for our resident physicians. Our primary hypothesis is that resident physician microsystem teams that receive this educational intervention will improve outcomes for patients with chronic obstructive pulmonary disease, chronic heart failure, ischemic heart disease, and pneumonia. Our secondary hypothesis is that these resident physicians will increase their core learning and functional ability in healthcare systems, clinical improvement, and interprofessional care. Research Plan: Medical education is integral to VHA, but there is no clear understanding its effect on VHA's core mission of providing high quality care to our Nation's veterans. Clinical microsystem theory offers a framework for understanding and improving focused healthcare systems but has not been tested in educational settings. Educational theory regarding the development of skills shows that the most effective learning in adults occurs when learners apply complex concepts in a particular context. Few educational studies consider this link between the contextual frameworks (i.e., microsystem) and learning efficacy. All successful examples of residents learning about clinical improvement involve a combination of knowledge and experience-based activities. We posit that the most effective method for residents to learn and practice clinical improvement is to integrate this work into the resident team microsystem. Methodology: We will use a randomized, clustered design with early and late intervention groups. An Internal Medicine team microsystem at WRJVA will be the level of intervention and analysis for clinical outcomes. Individual resident physicians will be the level of analysis for educational outcomes. Phase 1 will include preparing the educational intervention, pilot testing the components, and developing the Team Field Reports (TFR). Phase 2 will involve the delivery of the intervention, monthly updates to the TFRs, and analysis of midpoint data. In Phase 3, we will conclude the intervention, prepare manuscripts, and work to fully integrate the effective elements. Analysis will employ statistical process control charts for clinical data and interrupted time series analysis for educational knowledge, satisfaction, and self-efficacy. Qualitative techniques will be used to design and analyze information from our key stakeholder focus groups.